Archives of Clinical Neuropsychology 22 (2007) 9911001

Language of administration and neuropsychological test

performance in neurologically intact Hispanic
American bilingual adults
Philip Gerard Gasquoine
a,
, Kristin L. Croyle
a
,
Cynthia Cavazos-Gonzalez
b
, Omar Sandoval
a
a
Department of Psychology and Anthropology, University of Texas-Pan American,
1201 W. University Drive, Edinburg, TX 78539, United States
b
Pinkerman & Gonzalez, 2529 W. Trenton, Edinburg, TX 78539, United States
Accepted 12 August 2007
Abstract
This study compared the performance of Hispanic American bilingual adults on Spanish and English language versions of a
neuropsychological test battery. Language achievement test scores were used to divide 36 bilingual, neurologically intact, Hispanic
Americans from south Texas into Spanish-dominant, balanced, and English-dominant bilingual groups. They were administered
the eight subtests of the Bateria Neuropsicologica and the Matrix Reasoning subtest of the WAIS-III in Spanish and English.
Half the participants were tested in Spanish rst. Balanced bilinguals showed no signicant differences in test scores between
Spanish and English language administrations. Spanish and/or English dominant bilinguals showed signicant effects of language
of administration on tests with higher language compared to visual perceptual weighting (Woodcock-Munoz Language Survey-
Revised, Letter Fluency, Story Memory, and Stroop Color and Word Test). Scores on tests with higher visual-perceptual weighting
(Matrix Reasoning, Figure Memory, Wisconsin Card Sorting Test, and Spatial Span), were not signicantly affected by language
of administration, nor were scores on the Spanish/California Verbal Learning Test, and Digit Span. A problem was encountered in
comparing false positive rates in each language, as Spanish norms fell belowEnglish norms, resulting in a much higher false positive
rate in English across all bilingual groupings. Use of a comparison standard (picture vocabulary score) reduced false positive rates
in both languages, but the higher false positive rate in English persisted.
2007 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.
Keywords: Spanish speakers; Neuropsychological evaluation; Neuropsychological norms
In clinical neuropsychological evaluations, an attempt is made to relate low scores on cognitive tests to structural
brain impairment. There are a number of confounding demographic factors that can inuence this equation including
age, education, gender, and race/ethnicity. Neuropsychological tests norms have typically been stratied by age and
education and to a lesser extent by gender and race/ethnicity to counteract these effects. One of the stumbling blocks
unique to the use of race/ethnoculture as a normative variable concerns its operational denition (Gasquoine, 1999).

Corresponding author. Tel.: +1 361 888 7999; fax: +1 956 381 3333.
E-mail address: drgdrg13@yahoo.com (P.G. Gasquoine).
0887-6177/$ see front matter 2007 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.acn.2007.08.003
992 P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001
English language uency is one possible operational denition, relevant to the assessment of bilingual Hispanic
Americans. Hispanic Americans are the largest foreign language speaking racial/ethnocultural minority within the
United States making up about 12% of the population. At the last census 78% of Hispanic Americans over the age of
ve reported speaking Spanish at home (U.S. Bureau of the Census, 2000).
Spanish language neuropsychological test instruments have been published for use with Hispanic American
adults (1865 age range). Ardila, Rosselli, and Puente (1994) described tests of orientation and attention, lan-
guage, memory, and spatial and praxic abilities, that included translations of popular English tests (e.g., Boston
Diagnostic Aphasia Exam; Mini-Mental State Examination; Wechsler Memory Scale). The Neuropsychologi-
cal Screening Battery for Hispanics (NeSBHIS; Ponton et al., 1996) is an 80-min screening battery assessing
language, memory, visual-perceptual functioning, mental control, psychomotor functioning, and reasoning. The
NEUROPSI (Ostrosky-Solis, Ardila, & Rosselli, 1999) is a 30-min screening battery designed to assess orien-
tation, attention, memory, language, visual-perceptual, and executive functions. The Bateria Neuropsicologica en
Espanol (Artiola i Fortuny, Hermosillo, Heaton, & Pardee, 1999) has eight tests of attention, memory, and exec-
utive functions that are all adaptations of popular English language tests (e.g., Wisconsin Card Sorting Test). The
Bateria-R (Woodcock & Munoz-Sandoval, 1996), the Spanish version of the Woodcock-Johnson Psychoeducational
Battery-Revised, has been described as . . . the most comprehensive, properly validated and normed intelligence
test available for use with Spanish-speaking immigrants (Schrauf, Weintraub, & Navarro, 2006, p. 393). It has
39 subtests (e.g., processing speed, long-term retrieval) covering cognitive abilities, oral language, and academic
achievement.
These tests were all intended for use with monolingual Spanish-speaking adults and, except for the NeSBHIS that
was normed in Los Angeles on a group that was 30% bilingual, mostly have norms collected from foreign countries:
Ardila et al. (1994) in Colombia; Ostrosky-Solis et al. (1999) in Mexico; Artiola i Fortuny et al. (1999) in Spain and
the United States-Mexico border region (19% were United States residents; 17% of the total was bilingual); and the
Bateria-R mostly from Mexico, Puerto Rico, Costa Rica, Spain, and Peru, (34% were United States residents). This
raises the issue of howsuitable these norms are for Hispanic American adults, many of whomare better characterized as
bilingual. Hispanic Americans who are monolingual Spanish speakers are more frequently found amongst the elderly,
judging by the age breakdown of participants in neuropsychological studies reviewed by Gasquoine (2001). Within
the adult age range, Spanish monolinguals tend to be foreign born, recent immigrants, and poorly educated (Artiola i
Fortuny et al., 2005).
Artiola i Fortuny, Heaton, and Hermosillo (1998) argued that Hispanic Americans . . . do not maintain bilingual
status and tend to lose prociency in their language of origin to a signicant degree (p. 365), but this observation is
probably less applicable to Hispanic Americans who reside in certain enclaves within the United States where Spanish
and English languages are both widely used. One such enclave is the Rio Grande Valley region of Texas, a collection
of small communities and towns on the Mexican border stretching from Laredo, south of San Antonio to Brownsville,
on the Gulf of Mexico. Over 90% of area residents are Hispanic American, many of whom are subjectively uent in
both languages, able to switch easily between languages, and have little accent in either language. Participants in this
study were all residents from this area.
The existing literature comparing neurologically intact Hispanic American bilingual adults on Spanish and English
versions of neuropsychological tests is quite small. Harris, Cullum, and Puente (1995) presented Spanish and English
word-lists within a modied California Verbal Learning Test format (ve learning trials, a nonverbal interference
task, and a 3 min delayed free recall) to groups of balanced bilinguals, Spanish-dominant bilinguals, and English
monolinguals. Balanced bilinguals recalled an equivalent number of words in either language, whereas language
dominant groups performed better in their dominant language.
Ardila et al. (2000) administered four verbal memory tests and a verbal math test in Spanish and English to a group
of bilingual graduate students living in Miami, Florida. As the researchers were primarily interested in interference
between participants rst and second languages, the language of administration was alternated within a single session.
Several signicant differences were found, but interpretation of the results was compromised as the relative uency of
participants in each language was not factored into the analysis.
Rosselli et al. (2002) administered the Golden version of the Stroop Color and Word Test to groups of bilinguals
and Spanish and English monolinguals. Time to read all words was measured instead of the usual score (number of
responses in 45 s). Bilinguals were slower than monolinguals in the color naming condition. Within the bilingual group,
scores were similar in Spanish and English.
P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001 993
Gollan, Montoya, and Werner (2002) administered English language semantic and letter uency tasks to groups
of English-dominant bilinguals and English monolinguals. Bilinguals scored below monolinguals on both cate-
gory types. When bilinguals were able to answer in both Spanish and English they were unable to improve their
performance.
These results suggest that: (a) bilinguals typically perform more poorly than monolinguals on neuropsychological
tests; and (b) language of administration does not affect the performance of balanced bilinguals. Four methodologi-
cal considerations from these studies inuenced the current design. First, the characteristics of bilingual participants
differed across studies, indicating that criteria used to dene bilingualism are critically important (see Grosjean, 1998
for review). Two types of criteria were used: (a) self-report likert rating scales of Spanish/English uency (Ardila
et al., 2000; Gollan et al., 2002; Rosselli et al., 2002); and (b) difference scores from Spanish and English admin-
istrations of an oral expression measure (Harris et al., 1995), or the Boston Naming Test (Rosselli et al., 2002).
Rhodes, Ochoa, and Ortiz (2005) noted that single test measures do not provide a comprehensive measure of bilin-
gual abilities, which can vary across oral expressive, listening, reading, and writing skills in both languages. Second,
apparent language uency differences among bilingual groups could potentially reect more generalized intellec-
tual differences. Harris et al. (1995) added a measure of visual-perceptual intelligence (Ravens Colored Progressive
Matrices) to account for this variable. Third, a procedural confound with language of administration arose in the
comparisons of monolingual versus bilingual groups. Either, the bilingual group was tested twice and the monolingual
groups only once (Rosselli et al., 2002), or the monolingual groups were tested in a language they did not under-
stand (Harris et al., 1995), or only one language of administration was used (Gollan et al., 2002). This raises the
question of whether monolingual versus bilingual is the correct conceptual comparison in studies on the effect of
language of administration. Fourth, information derived from studies of single tests (often with unique administration
formats) provided limited information regarding clinical use where comparisons of performance across multiple tests
are crucial.
Consequently this study: (a) compared self-report and achievement test measures of bilingualism; (b) dened
bilingualism by using a comprehensive achievement test measure of language uency; (c) included an estimate of
visual-perceptual intelligence on which to compare groups; (d) avoided monolingual versus bilingual comparisons
by viewing bilingualism as a continuum ranging from English dominant through balanced to Spanish dominant; and
(e) used standardized administration procedures with a battery of neuropsychological tests, as would occur in clinical
settings.
The effect of language of administration on neuropsychological test performance in neurologically intact Hispanic
Americans was determined by comparing Spanish and English: (a) scores; and (b) false positive impairment rates (i.e.,
neurologically intact individuals incorrectly classied as showing cognitive impairment). Based on the literature review,
it was hypothesized that language of administration would produce higher scores and lower false positive impairment
rates in the dominant language of Spanish and English dominant bilinguals, but that language of administration would
have no effect for balanced bilinguals.
1. Methods
1.1. Participants
Thirty-six Spanish/English bilingual adults from the Rio Grande Valley were recruited by word-of-mouth and paid
$50 to participate. Consecutive volunteers were considered if they were subjectively able to carry on a conversation
in both languages. They were screened to ensure they had no history of neurological or psychiatric disorder including
drug or alcohol abuse.
There were 13 males and 23 females ranging in age from 20 to 65 (M=31.7, S.D. =11.8) years. Education ranged
from 9 to 18 (M=14.4, S.D. =2) years. Participants were either born in the United States (22) or Mexico (14). Those
born in Mexico had lived in the United States from 3 to 25 (M=13.5, S.D. =7) years. Those born in the United States
were all of Mexican heritage, as determined by ancestry.
Most participants were educated in the United States (28), with four being educated in Mexico, and four in both
countries. For most (32), Spanish was their rst language. Second language acquisition usually began at school. Most
(28) still spoke Spanish at home.
994 P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001
1.2. Measures
1.2.1. Self-report of Spanish/English uency
Two self-report measures of Spanish/English uency were obtained by asking each participant to: (a) indicate their
current preferred language for conversation from amongst the triad: Spanish; English; Both; and (b) rate their
current ability to speak/understand, Spanish/English on ve-point likert scales with the anchors of minimal to high.
These ratings were collapsed into a single difference score by subtracting the sum of the two English uency ratings
from the sum of the two Spanish uency ratings. A positive score indicated greater self-rated prociency in Spanish.
1.2.2. Achievement test estimates of Spanish/English uency
The Woodcock Munoz Language Survey-Revised (WMLS-R; Woodcock, Munoz-Sandoval, Ruef, & Alvarado,
2005) English Form A and Spanish versions were administered. Each version has seven subtests (Picture Vocabu-
lary, Verbal Analogies, Letter-Word Identication, Dictation, Understanding Directions, Story Recall, and Passage
Comprehension) and generates a total cluster scale score. Age-corrected norms (M=100, S.D. =15) were used.
1.2.3. Visual-perceptual intelligence
This was estimated from the Matrix Reasoning subtest of the Wechsler Adult Intelligence Scale-III (WAIS-III;
Wechsler, 1997a). This performance subtest has items requiring visual-perceptual matches of sameness and symmetry
and the solving of visual-perceptual analogy problems. It yields scale scores (M=10, S.D. =3) from age-corrected
norms. Instructions were translated into Spanish using standard back-translation techniques.
1.2.4. Neuropsychological test battery
The Bateria Neuropsicologica en Espanol (Artiola i Fortuny et al., 1999) was chosen since it consists entirely of
adaptations to English tests, obfuscating the need for tests to be translated. This battery consists of eight tests: (a) Story
Memory: Adapted fromHeaton, Grant, and Matthews (1991), the paragraph content differs fromthe English version but
both are scored out of 29. (b) Spanish Verbal Learning Test: The format parallels the California Verbal Learning Test-II
(Delis, Kramer, Kaplan, &Ober, 2000) with different words. (c) Digit Span: This test of working memory has the same
format as the WAIS-III subtest. Number sequences were translated from the WAIS-R (Wechsler, 1981). (d) Spanish
Letter Fluency: This test of executive function has the same format as the Word Fluency subtest of the Neurosensory
Center Comprehensive Examination for Aphasia (Spreen & Benton, 1969), but uses the letters P, M, and R. (e) Figure
Memory: Adapted from Heaton et al. (1991), this visual-perceptual learning test uses the three geometric gures from
the Wechsler Memory Scale (WMS; Wechsler, 1945). (f) Wisconsin Card Sorting Test: This test of executive function
has the same format as Heaton, Chelune, Talley, Kay, & Curtiss, 1993). (g) Visual Span: This visual-perceptual analog
of Digit Span has the same format as the Spatial Span subtest of the WMS-III (Wechsler, 1997b). (h) Stroop Color and
Word Test: This test of executive functions has the same format as Golden and Freshwater (1998).
Overall, this battery generated 33 different measures. To reduce the experimentwise probability of making a type
I error, a single measure was selected for analysis from each of the eight tests (see Table 1). Measures chosen were
considered to be among the most critical for a clinician to use in determining the presence/absence of cognitive
impairment. Norms used were age and education corrected from the United StatesMexico border region as published
in the manual. An exception was Digit Span Total where WMS-III norms were used in both Spanish and English as
the Bateria Neuropsicologica norms were separated for forward and backward administrations, which have no English
equivalent in either the WAIS-III or the WMS-III.
Table 1
Neuropsychological test measures
Story Memory Long-delay free recall (maximum=29)
Verbal Learning Long-delay free recall (maximum=16)
Digit Span Total forward and backward
Letter Fluency Total (P, M, and R in Spanish; F, A, and S in English)
Figure Memory Long-delay free recall (maximum=21)
Wisconsin Card Sort Total errors
Visual Span Total forward
Stroop Color and Word Numbers of colors read in the interference condition in 45 s
P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001 995
The English neuropsychological test battery consisted of the original tests upon which the Bateria Neuropsicologica
was based. Verbal Letter Fluency used the letters F, A, and S. Digit and tapping sequences for Digit Span and Visual
Span, respectively, were from the WMS-III.
Originally published norms were used for the California Verbal Learning Test-II, Digit Span, Wisconsin Card Sorting
Test, and Visual Span. Age-corrected meta-analytical norms (Mitrushina, Boone, Razani, & DElia, 2005) were used
for Verbal Letter Fluency and the Stroop Color and Word Test. Story Memory and Figure Memory used the gender,
age, and education corrected Caucasian norms from Heaton, Miller, Taylor, & Grant (2004), as there were no separate
tables for Hispanics.
1.3. Procedure
Participants were tested over two sessions 1461 (M=25, S.D. =8.9) days apart. At each session, only Spanish
or English was used by the bilingual examiner and participants were instructed that they could only respond in that
same language. Half the participants (randomly chosen) were tested in Spanish at the rst session and English at
the second. Self-report of Spanish/English uency was assessed only at the rst session in the language assigned.
The achievement test, visual-perceptual intelligence test, and neuropsychological battery were administered at both
sessions in the language assigned. The length of each session was approximately 2 h.
For each participant, the WMLS-R total cluster score in English was subtracted from that in Spanish. The resulting
difference scores (positive scores indicate greater Spanish uency) ranged from 40 to +73. These scores were used
to form three groups of participants: (a) English-dominant bilingual (EDB; WMLS-R SpanishEnglish total cluster
difference score 10; (b) balanced bilingual (BB; WMLS-R SpanishEnglish total cluster difference score between
9 and +9); and (c) Spanish-dominant bilingual (SDB; WMLS-RSpanish-English total cluster difference score +10).
The cutoff points were chosen post hoc in such a fashion as to produce roughly equal numbers in each group.
False positive impairment rates were calculated using both population norms (Heaton et al., 2004, p. 23) and
individual comparison standards (estimated premorbid ability levels). Afalse positive normative score was dened as a
score greater than 1 S.D. belowthe mean of published norms (Heaton et al., 2004). Based upon the normal distribution,
it was expected that 15% of scores would be false positive.
Individual comparison standards are more suitable for use in clinical neuropsychology when premorbid cognitive
abilities are suspected to be at the ends of the normal curve. There is no generally accepted individual comparison
standard in clinical neuropsychology (see Lezak, Howieson, & Loring, 2004, p. 91 for review). Vocabulary scores
(WMLS-RPicture Vocabulary subtest) were chosen as they have been widely used with adults, based upon the premise
that over learned information of this type is relatively insensitive to brain impairment in the absence of frank aphasic
symptoms. False positive individual comparison scores were dened as scores more than 1 S.D. below the WMLS-R
Picture Vocabulary score if the latter score was <100 (50th percentile). If the latter score was 100 then scores below
the 16th percentile were deemed false positive. In these cases false positive normative and individual comparison scores
were, by denition, the same.
2. Results
Table 2 shows the means (and standard deviations) for age, education, and Matrix Reasoning scale scores for each
group. The latter scores represented the average of the Spanish and English administrations. One-way ANOVAs showed
that the groups did not differ signicantly in age (F
2, 33
=1.4, ns), education (F
2, 33
<1, ns), or Matrix Reasoning scale
Table 2
Means (and standard deviations) for age, education, and Matrix Reasoning scale score (averaged over Spanish and English language administrations)
of the English-dominant bilingual, balanced bilingual, and Spanish-dominant bilingual groups
English-dominant Balanced Spanish-dominant
N 11 14 11
Age 27.1 (8.9) 31.2 (9.5) 35.6 (16)
Education 14.6 (1.7) 14.4 (2) 14.4 (2.5)
Matrix Reasoning 11.4 (2.3) 10.7 (2.6) 10.4 (2)
996 P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001
Table 3
Means (and standard deviations) for all participants on Woodcock Munoz Language Survey-Revised (WMLS-R), matrix reasoning, and the eight
tests of the Bateria Neuropsicologica by language of administration
Language of administration
English Spanish
WMLS-R cluster scale score 85.8 (14.5) 87.9 (19.7)
Matrix Reasoning scale score 11.3 (2.3) 10.7 (2.8)
Story Memory long-delay free recall score
*
13.9 (4.2) 15.5 (3.7)
Verbal learning long-delay free recall score 12.2 (2.9) 12.4 (2.6)
Digit Span total scale score
*
9.5 (2.4) 8.7 (1.9)
Letter Fluency total score 33.6 (11.6) 36.5 (13.2)
Figure Memory long-delay free recall score 17.3 (2.4) 17.9 (2.6)
Wisconsin Card Sort total errors 25.3 (17.3) 26.2 (25.7)
Visual Span forwards 7.8 (1.6) 7.8 (1.6)
Stroop Color and Word interference condition 42.2 (7.3) 41.2 (8.5)
*
p <.05.
score (F
2, 33
<1, ns). Although the difference did not reach statistical signicance, the mean age comparison between
the SDB(35.6) and EDB(27.1) groups had an effect size in the mediumrange (d =.7) and may have reached signicance
with a larger sample size. This was the only intergroup demographic comparison with an effect size in the medium
range or higher.
2.1. Comparison of self-report of Spanish/English uency ratings with WMLS-R total cluster difference score
WMLS-R total cluster difference scores correlated signicantly with the self-report triad measure (r =.77, p <.001)
and with self-report likert difference scores (r =.76, p <.001). The self-report triad variable correctly classied
26/36 =72% of participants into groups. The self-report likert difference score correctly classied 23/36 =64% (bal-
anced bilingualism was dened as a difference score of zero).
2.2. Group Xlanguage of administration comparisons
Table 3 shows means (and standard deviations) for WMLS-R, Matrix Reasoning, and the eight tests of the Bateria
Neuropsicologica for Spanish and English administrations. Note that all comparisons involved raw scores except for
those involving WMLS-R, Matrix Reasoning, and Digit Span, which use standardized scores. Scores were analyzed
in ten 3 (group) 2 (language of administration) mixed ANOVAs with language of administration as the repeated
measure.
None of the simple main effects for group were signicant. Simple main effects for language of administration
were signicant for Story Memory (F
1, 33
=8.2, p <.05,
2
=.2) and Digit Span (F
1, 33
=8.1, p <.05,
2
=.2). For Story
Memory, participants had a signicantly higher long-delay free recall mean score in Spanish (15.5) than English (13.9).
For Digit Span, English producing a signicantly higher total mean scale score (9.5) than Spanish (8.7).
Table 4 shows means (and standard deviations) for the three bilingual groups on WMLS-R, Matrix Reasoning, and
the eight tests of the Bateria Neuropsicologica by language of administration. Interaction effects were signicant for
WMLS-R (F
2, 33
=44.6, p <.0005,
2
=.73), Story Memory (F
2, 33
=6.1, p <.05,
2
=.27), Letter Fluency (F
2, 33
=6.7,
p <.005,
2
=.29), and Stroop Color and Word, (F
2, 33
=5.13, p <.05,
2
=.24). The size of the effect of language of
administration was large for WMLS-R and small for Story Memory, Letter Fluency, and Stroop Color and Word.
Interaction effects were further analyzed using the Scheffe procedure. For WMLS-R the EDB group mean was
signicantly higher in English than Spanish, the SDB group mean was signicantly higher in Spanish than English,
and the BB group means did not differ between Spanish and English. For both Story Memory and Letter Fluency the
SDB group means were signicantly higher in Spanish than English, whereas the BB and EDB group means were not
signicantly different between Spanish and English. For Stroop Color and Word the EDBgroup mean was signicantly
higher in English than Spanish, whereas BB and SDB group means did not differ between Spanish and English.
P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001 997
Table 4
Means (and standard deviations) for the English-dominant, balanced, and Spanish-dominant bilingual groups on Woodcock Munoz Language
Survey-Revised (WMLS-R), Matrix Reasoning, and the eight tests of the Bateria Neuropsicologica by language of administration
Group/language English-dominant Balanced Spanish-dominant
English Spanish English Spanish English Spanish
WMLS-R
***
95.4
a
(13.3) 72.5
a
(17.4) 85.3 (9.7) 84.9 (12.4) 77
a
(16) 107.2
a
(13.3)
Matrix Reasoning 11.7 (1.8) 11.2 (3) 10.7 (2.6) 10.7 (3) 10.7 (2.3) 10(2.4)
Story Memory
*
16.4 (2.6) 16.2 (2.9) 13.4 (4.4) 14(4.6) 12.1
a
(4.3) 16.7
a
(2.5)
Verbal Learning 13(2.4) 12.5 (2.1) 12.3 (3) 12.3 (3.3) 12.2 (2.9) 12.6 (2.3)
Digit Span 9.7 (2.4) 8.5 (2.5) 8.9 (2.2) 8.7 (1.7) 10.1 (2.5) 9(1.7)
Letter Fluency
**
37.9 (13) 32(10.9) 32.1 (9.5) 35.5 (15.8) 31.4
a
(12.5) 42.4
a
(10.2)
Figure Memory 18(1.7) 18.4 (2.3) 16.3 (2.7) 17.6 (3.2) 17.8 (2.4) 18(2)
Wisconsin CST 19.8 (12.4) 22.4 (25.2) 32.5 (21.5) 26(24.7) 21.4 (12.9) 30.3 (29.1)
Visual Span 7.1 (1.6) 7.4 (1.8) 8.3 (1.9) 8.3 (1.7) 7.8 (1.1) 7.4 (1.3)
Stroop
*
42.9
a
(7.5) 37.3
a
(8.4) 40.1 (9.1) 42.1 (9) 44.3 (3.7) 44.1 (7.2)
a
Denote pairs of means that differ signicantly from each other.
*
p <.05.
**
p <.005.
***
p <.0005.
2.3. Comparison of individual neuropsychological test scores with published norms and individual comparison
standards
Table 5 shows the number of participants in each group who obtained false positive normative scores on Matrix
Reasoning and the eight tests of the Bateria Neuropsicologica in Spanish and English. For all groups combined there
were more false positive normative scores in English (77) than Spanish (52). The expected number was 49. The SDB
group with Spanish was the group x language condition with the lowest number of false positive normative scores (8;
expected 15). The EDB group had similar numbers in English and Spanish (20 and 22, respectively; expected 15 each),
and the BB group had fewer in Spanish (22; expected 19) than English (35; expected 19). In both Spanish and English,
tests with the highest number of false positive normative scores were the same: Letter Fluency (13 in Spanish, 21 in
English); Stroop Color and Word (10 and 13); and Story Memory (9 and 14). The expected number for each test was
ve in each language.
Table 6 shows the number of participants who obtained false positive individual comparison scores on Matrix
Reasoning and the eight tests of the Bateria Neuropsicologica in Spanish and English. For all groups combined there
were more false positive individual comparison scores in English (34) than Spanish (14). The EDB group with Spanish
was the group language condition with the lowest number of false positive individual comparison scores (0). The
Table 5
False positive normative scores on Matrix Reasoning and the Bateria Neuropsicologica for the English-dominant, balanced, and Spanish-dominant
bilingual groups in Spanish and English
Language of administration Group MR SM VL DS LF FM WCST VS ST Total
English English-dominant (N=11) 0 1 2 2 5 0 1 4 5 20
English Balanced (N=14) 1 6 3 2 9 1 5 2 6 35
Spanish-dominant (N=11) 0 7 4 0 7 0 1 1 2 22
Total 1 14 9 4 21 1 7 7 13 77
Spanish English-dominant (N=11) 1 3 3 2 4 1 1 1 6 22
Spanish Balanced (N=14) 1 5 3 1 6 1 1 2 2 22
Spanish-dominant (N=11) 0 1 0 0 3 0 1 1 2 8
Total 2 9 6 3 13 2 3 4 10 52
Key. MR: Matrix Reasoning scale score; SM: Story Memory long-delay free recall score; VL: Spanish/California Verbal Learning long-delay free
recall score; DS: Digit Span total scale score; LF: Spanish/Verbal Letter Fluency total score; FM: Figure Memory long-delay free recall score;
WCST: Wisconsin Card Sort total errors; VS: Visual Span forwards score; ST: Stroop Color and Word total colors read in the interference condition.
998 P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001
Table 6
False positive individual comparison scores on Matrix Reasoning and the Bateria Neuropsicologica for the English-dominant, balanced, and
Spanish-dominant bilingual groups in Spanish and English
Language of administration Group MR SM VL DS LF FM WCST VS ST Total
English English-dominant (N=11) 0 1 0 1 2 0 0 4 5 13
English Balanced (N=14) 1 6 0 0 2 0 3 1 2 15
Spanish-dominant (N=11) 0 4 0 0 1 0 0 0 1 6
Total 1 11 0 1 5 0 3 5 8 34
Spanish English-dominant (N=11) 0 0 0 0 0 0 0 0 0 0
Spanish Balanced (N=14) 1 1 0 0 1 1 1 1 1 7
Spanish-dominant (N=11) 0 1 0 0 2 0 1 1 2 7
Total 1 2 0 0 3 1 2 2 3 14
Key. MR: Matrix Reasoning scale score; SM: Story Memory long-delay free recall score; VL: Spanish/California Verbal Learning long-delay free
recall score; DS: Digit Span total scale score; LF: Spanish/Verbal Letter Fluency total score; FM: Figure Memory long-delay free recall score;
WCST: Wisconsin Card Sort total errors; VS: Visual Span forwards score; ST: Stroop Color and Word total colors read in the interference condition.
SDB group had similar numbers in Spanish and English (7 and 6, respectively), while the BB group had fewer in
Spanish (7) than English (15). In English, the tests with the highest number of false positive individual comparison
scores were: Story Memory (11), Stroop Color and Word (8), and Letter Fluency/Visual Span (both 5). Stroop Color
and Word and Letter Fluency had the highest number in Spanish (3).
3. Discussion
The study was designed to evaluate the effect of language of administration on neuropsychological test performance
in neurologically intact Hispanic American bilinguals. The hypothesis that language of administration would produce
higher scores in the dominant language of Spanish or English dominant bilinguals was conrmed for some tests but
not others. The hypothesis that language of administration would have no signicant effect on test scores for balanced
bilinguals was conrmed. Hypotheses that related to the interpretation of false positive impairment rates in each
language were compromised as the distribution of Spanish language norms fell below that of the English language
norms.
WMLS-R cluster scores demonstrated wide variability between the Spanish and English uency of subjectively
bilingual participants. When used to distinguish Spanish dominant, balanced, and English dominant bilingualism, they
correlated highly with participant self-report. Participant self-report as measured by likert rating scales of differential
abilities (expression and comprehension) provided no advantage over simple, single participant statements of their
dominant language (the triad measure).
Stimuli of the Bateria Neuropsicologica were of comparable difculty in Spanish and English for all tests except
Story Memory, where the paragraph was easier to learn in Spanish than English, and Digit Span, where the digit
sequences were easier to repeat in English than Spanish. Longer digit spans in English than Spanish have been
attributed to differences in the phonological length of digits (e.g., Ardila et al., 2000). Letter uency combinations
of P, M, and R in Spanish and F, A, and S in English were not signicantly different. The Bateria Neuropsicologica
should be supplemented by measures of language, visual-perceptual processing, and ne motor skills if comprehensive
assessment is desired.
For balanced bilinguals, language of administration had no signicant effect on performance on any test. This was in
keeping with results from previous studies on single neuropsychological tests (Gollan et al., 2002; Harris et al., 1995;
Rosselli et al., 2002). Spanish dominant bilinguals did signicantly better on WMLS-R, Story Memory, and Letter
Fluency in Spanish, whereas English dominant bilinguals did signicantly better on WMLS-R and the Stroop Color
and Word Test in English. Effect sizes were large for WMLS-R and small for the other three tests. Subjectively, these
tests had higher language compared to visual-perceptual weighting than Matrix Reasoning, Figure Memory, Wisconsin
Card Sorting Test, and Spatial Span. The Spanish/California Verbal Learning Test and Digit Span also showed no effect
of language of administration. Presumably, the language weighting of these tests is less than would subjectively appear.
P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001 999
The sample was well-educated (as is typical of studies that involve the psychological testing of volunteers, Kaplan
& Sacuzzo, 2005, p. 363) and had superior visual perceptual processing skills to language processing skills. Mean
estimates of visual-perceptual intelligence were around the 60th percentile, while mean language achievement was
about the 20th percentile in both languages. The visual-perceptual intelligence estimate was closer to expected ability
levels, as judged from years of education completed.
This visual-perceptual versus language decrement was about double the performance IQminus verbal IQdecrement
typically reported for Hispanic Americans on English language intelligence tests. For example, this decrement was
half a S.D. in the Wechsler Intelligence Scale for Children-III normative sample (Pritera, Weiss, & Saklofske, 1998).
The relationship between the performanceverbal IQ difference and bilingualism is not known as intelligence test
publishers do not consider bilingualism a census-matching demographic.
Hispanic Americans are frequently characterized as having a language decit. For example, Sedo (2001) wrote
lowlanguage level eld sensitivity is . . . the characteristic learning style of many Hispanic people (p. 167). Evidence
for the existence of this decit comes solely from test score comparisons with monolinguals, a conceptualization
whose validity has been questioned (e.g., Grosjean, 1998; Rosselli et al., 2002). No functional limitation has ever been
associated with this decit.
The Bateria Neuropsicologica norms represent a distribution below that of English language norms. This was
clearly evidenced in comparisons of the number of false positive normative scores obtained in Spanish and English.
For example, the balanced bilingual group performed equally well in Spanish and English across all tests, yet English
norms generated 35 false positive normative scores compared to 22 with Spanish norms.
Spanish norms generated an overall false positive rate closer to the number expected from the normal distribution,
but this was misleading as false positive normative rates varied considerably amongst tests, with those having higher
language weightings (Letter Fluency, Stroop Color and Word Test, and Story Memory) generating higher false positive
normative scores in both languages.
Using an individual comparison approach reduced the overall number of false positives by nearly two thirds (individ-
ual comparison =48 versus normative =129) as the majority of participants had low scores on the comparison measure
chosen, picture vocabulary. The false positive normative rate in Spanish was reduced by nearly three quarters (5214),
while the rate in English was reduced by just over one half (7734).
Spanish norms for the Bateria Neuropsicologica were collected fromthe Mexico-Arizona border region on a sample
that was predominantly female (75%), resident of Mexico (60%), and monolingual (76%). A regression-based system
was used to develop norms stratied by age (5 levels) and education (7). With an N of 185 this equated to less than
six individuals per age education cell. Sample sizes on which English norms were based varied among tests but
norms for Story Memory and Figure Memory were constructed from the same regression-based system. Sample sizes
of 454 and 444, respectively, were stratied by gender (2 levels), age (11), and education (6), equating to less than four
individuals per gender age education cell. The validity of regression-based norms has been questioned when cell
sample sizes are so low (Fastenau & Adams, 1996).
Ultimately, decisions regarding the suitability of norms must consider the issue of sensitivity (i.e., true positive
ratescorrectly identied neurologically impaired individuals), as well as false positive rates. Sensitivity cannot be
determined in a study on neurologically intact individuals, so a denitive decision regarding the relative merits of the
Spanish and English norms for the assessment of bilinguals awaits additional investigation.
In summary: (a) Self-report of Spanish/English bilingualismcorrelated highly with differences on language achieve-
ment test scores. Since bilingualism is easily measurable and affects neuropsychological test performance, its adoption
as a census-matching variable needs to be considered by test publishers. (b) Language of administration had no sig-
nicant effect on the neuropsychological test scores of balanced bilinguals. (c) For Spanish and English dominant
bilinguals, language of administration tended to produce signicant effects on neuropsychological tests that subjec-
tively had higher language as compared to visual-perceptual weightings. The Spanish/California Verbal Learning Test
and Digit Span were the exception to this rule. (d) This well-educated (M=14.4 years) bilingual sample had superior
visual perceptual processing skills (60th percentile) compared to language processing skills (20th percentile) in both
languages. (e) The distribution for Spanish and English norms differed, resulting in higher false positive rates for the
latter. (f) Use of an individual comparison standard more than halved the false positive rate in each language.
The overall N was relatively small so ndings related to the non-signicant effects of language of administration
for Spanish and English dominant bilinguals on certain tests [see (c) in the last paragraph] must be viewed as tentative.
Some of these non-signicant effects of language of administration for Spanish and English dominant bilinguals were
1000 P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001
counterintuitive as they occurred on tests (Spanish/California Verbal Learning Test and Digit Span) with subjectively
high language weightings. On the other hand, non-signicant effects of language of administration for balanced
bilinguals [(b) in the last paragraph] were intuitive and supported by previous studies. Findings related to the different
false positive rates between Spanish and English [(e) and (f) in the last paragraph] were not affected by the size of
the sample as the Bateria Neuropsicologica norms represented a distribution below that of English language norms on
all tests. The other important limitation on the generalizability of the results of this study concerns the relatively high
education level of sample participants [see (d) in the last paragraph] and their everyday use of both Spanish and English
languages. All results should be viewed as pertaining strictly to similar groupings of Spanish/English bilinguals.
Ardila et al. (2000) outlined three possibilities regarding the direction clinical neuropsychology should take in the
assessment of Hispanic American bilinguals: (a) develop separate norms; (b) test in both languages and use both sets of
norms with . . . the one favoring the participant being preferred (p. 15); or (c) provide an adjustment to scores. Since
the goal in clinical neuropsychology is the detection of brain impairment it is difcult to know what might actually
favor a participant in the second possibility, however a decision between the rst and third possibilities requires further
study.
Acknowledgements
This research was supported by a grant to the rst two authors from the College of Social and Behavioral Sciences,
University of Texas-Pan American. Part of the data collected in this study was used in a thesis by the fourth author in
partial fulllment of the requirements for the degree of Master of Science in Clinical Psychology at the University of
Texas-Pan American.
References
Ardila, A., Rosselli, M., Ostrosky-Solis, F., Marcos, J., Granda, G., & Soto, M. (2000). Syntactic comprehension, verbal memory, and calculation
abilities in Spanish-English bilinguals. Applied Neuropsychology, 7, 316.
Ardila, A., Rosselli, M., & Puente, A. E. (1994). Neuropsychological evaluation of the Spanish speaker. New York: Plenum Press.
Artiola i Fortuny, L., Garolera, M., Hermosilio, D., Feldman, E., Barillas, H. F., Keefe, R., et al. (2005). Research with Spanish-speaking populations
in the United States: Lost in the translation. Journal of Clinical and Experimental Neuropsychology, 27, 555564.
Artiola i Fortuny, L., Heaton, R. K., & Hermosillo, D. (1998). Neuropsychological comparisons of Spanish-speaking participants from the
U.S.Mexico border region versus Spain. Journal of the International Neuropsychological Society, 4, 363379.
Artiola i Fortuny, L., Hermosillo, D., Heaton, R. K., & Pardee, R. E. (1999). Manual de normas y procedimientos para la bateria neuropsicologica
en Espanol. Tucson, AZ: m Press.
Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. (2000). California Verbal Learning Test-II: Manual. San Antonio, TX: The Psychological
Corporation.
Fastenau, P. S., & Adams, K. M. (1996). Heaton, Grant and Matthews comprehensive norms: An overzealous attempt. Journal of Clinical and
Experimental Neuropsychology, 18, 444448.
Gasquoine, P. G. (1999). Variables moderating cultural and ethnic differences in neuropsychological assessment: The case of Hispanic Americans.
The Clinical Neuropsychologist, 13, 376383.
Gasquoine, P. G. (2001). Research in clinical neuropsychology with Hispanic American participants: a review. The Clinical Neuropsychologist, 15,
212.
Golden, C. J., & Freshwater, S. M. (1998). The Stroop Color and Word Test: A manual for clinical and experimental uses. Wood Dale, IL: Stoelting.
Gollan, T. H., Montoya, R. I., & Werner, G. A. (2002). Semantic and letter uency in Spanish-English bilinguals. Neuropsychology, 16, 562576.
Grosjean, F. (1998). Studying bilinguals: Methodological and conceptual issues Bilingualism: Language and Cognition., pp. 131149.
Harris, J. G., Cullum, C. M., & Puente, A. E. (1995). Effects of bilingualism on verbal learning and memory in Hispanic adults. Journal of the
International Neuropsychological Society, 1, 1016.
Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., & Curtiss, G. (1993). Wisconsin Card Sorting Test manual: Revised and expanded. Odessa,
FL: Psychological Assessment Resources.
Heaton, R. K., Grant, I., & Matthews, C. G. (1991). Comprehensive norms for an expanded HalsteadReitan battery. Odessa, FL: Psychological
Assessment Resources.
Heaton, R. K., Miller, S. W., Taylor, M. J., & Grant, I. (2004). Revised comprehensive norms for an expanded HalsteadReitan battery: Demograph-
ically adjusted neuropsychological norms for African American and Caucasian adults. Odessa, FL: Psychological Assessment Resources.
Kaplan, R. M., & Sacuzzo, D. P. (2005). Psychological testing: Principles, applications and issues (6th ed.). Belmont, CA: Thompson.
Lezak, M. D., Howieson, D. B., & Loring, D. W. (2004). Neuropsychological assessment (4th ed.). New York, NY: Oxford University Press.
Mitrushina, M., Boone, K. B., Razani, J., & DElia, L. F. (2005). Handbook of normative data for neuropsychological assessment (2nd ed.). New
York, NY: Oxford University Press.
P.G. Gasquoine et al. / Archives of Clinical Neuropsychology 22 (2007) 9911001 1001
Ostrosky-Solis, F., Ardila, A., & Rosselli, M. (1999). NEUROPSI: A brief neuropsychological test battery in Spanish with norms by age and
education level. Journal of the International Neuropsychological Society, 5, 413433.
Ponton, M. O., Satz, P., Herrera, L., Ortiz, F., Urrutia, C. P., Young, R., et al. (1996). Normative data stratied by age and education for the
neuropsychological screening battery for Hispanics (NeSBHIS): Initial report. Journal of the International Neuropsychological Society, 2,
96104.
Pritera, A., Weiss, L. G., & Saklofske, D. H. (1998). The WISC-III in context. In A. Pritera & D. H. Saklofske (Eds.), WISC-III: Clinical use and
interpretation (pp. 138). San Diego: Academic Press.
Rhodes, R. L., Ochoa, S. H., & Ortiz, S. O. (2005). Assessing culturally and linguistically diverse students: A practical guide. New York: Guilford
Press.
Rosselli, M. A., Ardila, A., Santisi, M. N., Del Rosario Arecco, M., Salvatierra, J., Conde, A., et al. (2002). Stroop effect in Spanish-English
bilinguals. Journal of the International Neuropsychological Society, 8, 819827.
Schrauf, R. W., Weintraub, S., &Navarro, E. (2006). Is adaptation of the Word Accentuation Test of Premorbid Intelligence necessary for use among
older, Spanish-speaking immigrants in the United States? Journal of the International Neuropsychological Society, 12, 391399.
Sedo, M. A. (2001). Diagnosing learning disabilities in bilingual urban students: Aneuropsychological framework. In M. O. Ponton &J. Leon-Carrion
(Eds.), Neuropsychology and the Hispanic patient: A clinical handbook (pp. 165188). New Jersey: Lawrence Erlbaum Associates.
Spreen, O., & Benton, A. L. (1969). Neurosensory Center Comprehensive Examination for Aphasia. Victoria, BC: Neuropsychology Laboratory,
University of Victoria.
U.S. Bureau of the Census. (2000). Population reports: 2000. Washington, D.C.: Author.
Wechsler, D. (1945). A standardized memory scale for clinical use. Journal of Psychology, 19, 8795.
Wechsler, D. (1981). Wechsler Adult Intelligence Scale-R. San Antonio, TX: Psychological Corporation.
Wechsler, D. (1997a). Wechsler Adult Intelligence Scale-III. San Antonio, TX: Psychological Corporation.
Wechsler, D. (1997b). Wechsler Memory Scale-III. San Antonio, TX: Psychological Corporation.
Woodcock, R. W., & Munoz-Sandoval, A. F. (1996). Bateria Woodcock-Munoz: Pruebas de aprovechamiento-Revisada. Itasca, IL: Riverside.
Woodcock, R. W., Munoz-Sandoval, A. F., Ruef, M. L., &Alvarado, C. G. (2005). Woodcock-Munoz Language Survey-Revised. Itasca, IL: Riverside
Publishing.